a heart attack or any other cardiovascular diseases in very old men (Arteriosclerosis, 1992; 12: 416-23). Indeed, in the elderly, high cholesterol may even be protective. In one New York study, about twice as many individuals with low cholesterol had

a heart attack or died from one compared with those with the highest cholesterol levels (JAMA, 1994; 272: 1335-40).

In France, a team of researchers found that old women with very high cholesterol live the longest. The death rate was more than five times higher for women who had very low cholesterol, and the report actually warned against lowering cholesterol in elderly women (Lancet, 1989; i: 868-70).

Blood cholesterol is also apparently not important in men who've already had a heart attack. A Canadian study of 120 men 10 years after recovery from a heart attack showed that those with low cholesterol had a second coronary as often as those with high cholesterol (Can Med Assoc J, 1970; 103: 927-31). In Russia, low cholesterol is associated with an increased risk of CHD (Circulation, 1993; 88: 846-53).

According to the data, high cholesterol is dangerous for Americans, but not for Canadians, Stockholmers, Rus-sians or Maoris. It's dangerous for men but not women, for healthy men but not coronary patients, and for men of 30 but not over 48. Such discrep-ancies indicate that the association between high cholesterol and CHD is not due to simple cause and effect. The most likely interpretation is that high cholesterol is not dangerous in itself, but a marker for something else.

One study might be illuminating. A study of CHD in Japanese immigrants found that high cholesterol increased their risk of CHD but, if they maintained their cultural traditions, they were protected against heart attacks. Indeed, those who adopted an American way of life, but preferred lean Japanese food, had coronary disease twice as often as those who maintained Japanese traditions, but consumed a high-fat diet. According to the study, there is something in the Japanese lifestyle that

protects against CHD, and it's not

the food.

The study postulated that certain factors in traditional Japanese culture are protective: the Japanese place great emphasis on group cohesion, group achievement and social stability. Members of the stable Japanese society enjoy the support of other members and, thus, are protected from the emotional and social stress that could be a more important cause of heart disease than diet. The Japanese tradition of togetherness contrasts dramatically with the typical Western emphasis on social and geographic mobility, individualism and striving ambition.

!AUffe Ravnskov, MD

Dr Ravnskov has published nearly 40 papers disproving the cholesterol myth. This article has been adapted from his book, The Cholesterol Myths: Exposing the Fallacy That Saturated Fat and Cholesterol Cause Heart Disease

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